Diagnosis and Treatment of Syphilis
The Contra Costa Public Health HIV/STD Program maintains historical testing and treatment information on syphilis patients. Please call 925-313-6750 to find out if your patient has tested positive or been treated for syphilis in the past. The HIV/STD Program also offers clinical guidance. Or you can see the CDPH STD Treatment Guidelines referenced above or the CDC STD Treatment Guidelines
Syphilis staging
Stage
Clinical Manifestations
Serology testing results
Primary
Lesion at site of infection
Positive RPR and VDRL, TP-PA may be negative in early disease
Secondary
Rash, mucocutaneaous lesions, lymphadenopathy
Positive RPR, VDRL and TP-PA
Early latent
No evidence of primary or secondary syphilis with negative syphilis serology within past year
Positive RPR, VDRL and TP-PA
Late latent
No evidence of primary or secondary syphilis with positive syphilis serology of unknown duration
Positive RPR, VDRL and TP-PA. Treat if greater than 4 fold increase in VDRL titer (e.g. 1:4 to 1:16) or if patient never treated
Neurosyphilis or ocular syphilis
Cognitive deficits, ophthalmic or auditory sxs, cranial nerve palsies, signs or sxs of meningitis or stroke
Variable, see full CDC STD Treatment Guidelines
Congenital Syphilis staging
Stage
Clinical Manifestations
Evaluation
Early (up to 2 years of life)
Asymptomatic or with symptoms that overlap with other TORCH infections
Multiple manifestations, mainly nose, teeth and bone manifestations
Syphilis treatment
Stage
Preferred treatment
Alternative treatment
Primary, secondary and early latent syphilis
Benzathine penicillin G
2.4 million units IM x1
Pediatric dose: 50,000 U/Kg IM x 1 up to adult dose 2.4 million units
Doxycycline 100mg po bid x14 days or tetracycline 500mg po qid x14 days or
Ceftriaxone 1 gram (IM or IV) daily x10-14 days
Late latent
Benzathine penicillin G
2.4 million units IM weekly x3 weeks
Pediatric dose: 50,000 U/Kg IM up to 2.4 million units weekly x 3 weeks
Doxycycline 100mg po bid x28 days or tetracycline 500mg po qid x28 days
Neurosyphilis or ocular syphilis
Aqueous crystalline penicillin G 18-24 million U/day, administered as 3-4 million units IV q4 hours or continuous infusion for 10-14 days
Pediatric dose: 200,000-300,000 U/Kg/day IV every 4-6 hours x 10-14 days (no dot exceed adult dose)
Procaine penicillin G 2.4 million units IM per dayx10-14 days PLUS Probenicid 500 mg po qid x 10-14 days
Congenital syphilis
Depends on Red Book algorithm (see above) Aqueous crystalline penicillin x 10 days or Benzathine penicillin x 1 dose
Syphilis treatment in pregnancy
Parenteral penicillin G is the only therapy known to be effective in pregnancy. Pregnant women with penicillin allergy should be desensitized and treated with penicillin. For pregnant patients with late latent syphilis, the dosing interval for penicillin must be 7 days. If any dose is missed, therapy must be re-started.
Congenital syphilis
Usually acquired in utero at any gestational age in untreated or inadequately treated mothers, but may be acquired at time of delivery too. Symptoms may not be present at time of birth or are non-specific (similar to other intrauterine infections). In-utero death is also possible. Most important part of the evaluation of these infants is to know mom’s syphilis status during pregnancy and if syphilis positive during pregnancy – clinician needs to: 1) Review mother’s medical history including initial serologic results, treatment and follow up serologic results to determine if mother was treated appropriately, untreated or inadequately treated; and 2) Needs to compare mother’s results with neonates’ results and based on these, follow Red Book’s algorithm (see above) in conjunction with ID expert. Prevention: Early detection and treatment of maternal infection at least 30 days before delivery.
Follow-up and monitoring after treatment:
Clinical and serologic evaluation should be performed at 6 and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern. Serologic response (i.e., titer) should be compared with the titer at the time of treatment. However, assessing serologic response to treatment can be difficult, and definitive criteria for cure or failure have not been well established. In addition, nontreponemal test titers might decline more slowly for persons previously treated for syphilis (408,409(https://www.cdc.gov/std/tg2015/references.htm#408)).
Persons who have signs or symptoms that persist or recur and those with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks likely experienced treatment failure or were re-infected. These persons should be retreated and reevaluated for HIV infection. Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed; treatment should be guided by CSF findings.
Failure of nontreponemal test titers to decline fourfold within 6–12 months after therapy for primary or secondary syphilis might be indicative of treatment failure. However, clinical trial data have demonstrated that 15%–20% of persons with primary and secondary syphilis treated with the recommended therapy will not achieve the fourfold decline in nontreponemal titer used to define response at 1 year after treatment (406(https://www.cdc.gov/std/tg2015/references.htm#406),409(https://www.cdc.gov/std/tg2015/references.htm#409)). Serologic response to treatment appears to be associated with several factors, including the person’s stage of syphilis (earlier stages are more likely to decline fourfold and become negative) and initial nontreponemal antibody titers (lower titers are less likely to decline fourfold than higher titers) (409(https://www.cdc.gov/std/tg2015/references.htm#409)). Optimal management of persons who have less than a fourfold decline in titers after treatment of syphilis is unclear. At a minimum, these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection. If additional follow-up cannot be ensured, retreatment is recommended. Because treatment failure might be the result of unrecognized CNS infection, CSF examination can be considered in such situations.
This page has been edited 6 times. The last modification was made by - cfarnitano on Feb 17, 2017 4:07 pm
List of Clinic Referrals: Clinics offering STD testing and treatment in the bay area
List of suggested testing based on sexual activity: List of test based on sexual activity
Diagnosis and Treatment of Syphilis
The Contra Costa Public Health HIV/STD Program maintains historical testing and treatment information on syphilis patients. Please call 925-313-6750 to find out if your patient has tested positive or been treated for syphilis in the past. The HIV/STD Program also offers clinical guidance. Or you can see the CDPH STD Treatment Guidelines referenced above or the
CDC STD Treatment Guidelines
Syphilis staging
Congenital Syphilis staging
Syphilis treatment
2.4 million units IM x1
Pediatric dose: 50,000 U/Kg IM x 1 up to adult dose 2.4 million units
Ceftriaxone 1 gram (IM or IV) daily x10-14 days
2.4 million units IM weekly x3 weeks
Pediatric dose: 50,000 U/Kg IM up to 2.4 million units weekly x 3 weeks
Pediatric dose: 200,000-300,000 U/Kg/day IV every 4-6 hours x 10-14 days (no dot exceed adult dose)
Syphilis treatment in pregnancy
Parenteral penicillin G is the only therapy known to be effective in pregnancy. Pregnant women with penicillin allergy should be desensitized and treated with penicillin. For pregnant patients with late latent syphilis, the dosing interval for penicillin must be 7 days. If any dose is missed, therapy must be re-started.
Congenital syphilis
Usually acquired in utero at any gestational age in untreated or inadequately treated mothers, but may be acquired at time of delivery too. Symptoms may not be present at time of birth or are non-specific (similar to other intrauterine infections). In-utero death is also possible. Most important part of the evaluation of these infants is to know mom’s syphilis status during pregnancy and if syphilis positive during pregnancy – clinician needs to: 1) Review mother’s medical history including initial serologic results, treatment and follow up serologic results to determine if mother was treated appropriately, untreated or inadequately treated; and 2) Needs to compare mother’s results with neonates’ results and based on these, follow Red Book’s algorithm (see above) in conjunction with ID expert. Prevention: Early detection and treatment of maternal infection at least 30 days before delivery.
Follow-up and monitoring after treatment:
Clinical and serologic evaluation should be performed at 6 and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern. Serologic response (i.e., titer) should be compared with the titer at the time of treatment. However, assessing serologic response to treatment can be difficult, and definitive criteria for cure or failure have not been well established. In addition, nontreponemal test titers might decline more slowly for persons previously treated for syphilis (408,409(https://www.cdc.gov/std/tg2015/references.htm#408)).
Persons who have signs or symptoms that persist or recur and those with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks likely experienced treatment failure or were re-infected. These persons should be retreated and reevaluated for HIV infection. Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed; treatment should be guided by CSF findings.
Failure of nontreponemal test titers to decline fourfold within 6–12 months after therapy for primary or secondary syphilis might be indicative of treatment failure. However, clinical trial data have demonstrated that 15%–20% of persons with primary and secondary syphilis treated with the recommended therapy will not achieve the fourfold decline in nontreponemal titer used to define response at 1 year after treatment (406(https://www.cdc.gov/std/tg2015/references.htm#406),409(https://www.cdc.gov/std/tg2015/references.htm#409)). Serologic response to treatment appears to be associated with several factors, including the person’s stage of syphilis (earlier stages are more likely to decline fourfold and become negative) and initial nontreponemal antibody titers (lower titers are less likely to decline fourfold than higher titers) (409(https://www.cdc.gov/std/tg2015/references.htm#409)). Optimal management of persons who have less than a fourfold decline in titers after treatment of syphilis is unclear. At a minimum, these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection. If additional follow-up cannot be ensured, retreatment is recommended. Because treatment failure might be the result of unrecognized CNS infection, CSF examination can be considered in such situations.
This page has been edited 6 times. The last modification was made by -